Antibodies against phosphorylcholine in combination therapy with biologic agents

ABSTRACT

Antibodies against PC, PC conjugate or bioactive components and/or fragments thereof for use in combination therapy with one or more biologic agents and/or stem cells are disclosed, as well as compositions comprising the antibodies in combination with one or more biologic agents and/or stem cells. Also disclosed are PC conjugates, PC or bioactive components and/or parts/fragments thereof for use in activation immunotherapy prior to or in combination with treatment with biologic agents and/or stem cells for curing, treating, preventing, and/or reducing the risk of developing auto-immune diseases, chronic inflammatory diseases, and cancer diseases, as well as compositions comprising them in combination with biologic agents and/or stem cells.

CROSS REFERENCE TO RELATED APPLICATIONS

This application is a divisional application of U.S. Ser. No.15/149,969, having a filing date of May 9, 2016, which is a divisionalof U.S. Ser. No. 13/582,193, having a filing date of Aug. 31, 2012,which was a 371 application of International applicationPCT/EP2011/001090, filed Mar. 4, 2011, which claimed the benefit of U.S.provisional patent applications 61/310,519, filed Mar. 4, 2011 and61/349,410, filed May 28, 2010, all of said applications incorporatedherein by reference.

FIELD OF THE INVENTION

This invention relates to antibodies against PC, PC conjugate orbioactive components and/or fragments thereof for use in combinationtherapy with one or more biologic agents and/or stem cells in a mammal,as well as to compositions comprising the antibodies in combination withone or more biologic agents and/or stem cells. It also relates to PCconjugates, PC or bioactive components and/or parts/fragments thereoffor use in activation immunotherapy in a mammal prior to or incombination with the treatment of a mammal with biologic agents and/orstem cells for curing, treating, preventing, and/or reducing the risk ofdeveloping autoimmune diseases, chronic inflammatory diseases, andcancer diseases, as well as compositions comprising them in combinationwith biologic agents and/or stem cells. It also relates to the use ofantibodies against phosphorylcholine (PC), PC conjugate or bioactivecomponents and/or fragments thereof in combination therapy with one ormore biologic agents and/or stem cells in a mammal, as well as their usein the preparation of a medicament for use in such therapy.

BACKGROUND OF THE INVENTION

Chronic inflammatory, autoimmune, and cancer diseases are major healthproblems in the Western world and becoming increasingly so in developingcountries. These diseases include rheumatic conditions, such asrheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). Thelatter is often described as a prototypic systemic autoimmune disease,and more than 80 autoimmune rheumatic diseases have been described, cf.e.g. Harrison's Principles of Internal Medicine, 17th Edition.

Rheumatoid arthritis is a chronic inflammatory disease that affects0.5-1% of the general population¹. Cardiovascular disease (CVD)represents a major source of serious morbidity and mortality andaccounts for an increase in risk of approximately 60% for all RA-relateddeaths². Recently it was suggested that RA may be equal to diabetesmellitus type 2 as an independent risk factor for CVD³. TraditionalFramingham risk factors and inflammation-associated factors maycontribute to increased risk of CVD in RA⁴.

Cancer diseases represent a substantial challenge to the health caresystem and communities due to the high costs associated with treatment.The majority of patients experience a decrease of life quality duringtreatment. Some of the cancer diseases may be treated by biologicagents, which may be associated with side effects.

In recent years, the treatment of RA has improved due to theintroduction of biologics, including tumor necrosis factor (TNF)antagonists and B-cell-targeting agents such as rituximab. Severalstudies consistently indicate that anti-TNF treatment ameliorates therisk of CVD⁵. The effect of TNF blockade on the cardiovascularfunctions, such as, for example, arterial stiffness, is not clear, andthere are both positive⁶ and negative studies⁷. In addition, suppressionof inflammation in RA by TNF blockade has been shown to inducepro-atherogenic changes in lipid profiles⁸, but data on short-term andlong-term effects remain inconsistent⁹.

Rituximab inhibits B-cell function by targeting CD20, and isincreasingly used in rheumatic and autoimmune diseases, including RA,especially for treatment of patients who do not respond to anti-TNFtreatment¹⁰. Little is known about the exact role of B cells in CVD andatherosclerosis, but both pro- and anti-atherogenic effects have beensuggested¹¹⁻¹³. Recent studies indicate that short-term treatment withrituximab improves vascular function and dyslipidemia¹⁴; moreover, itdecreases pro-thrombotic biomarkers¹⁵. Thus, anti-CD20 treatment mayreduce future CVD risks in RA, but data are limited.

It has recently been reported that low levels of IgM natural antibodiesagainst phosphorylcholine (anti-PC) independently predict CVD¹⁶⁻¹⁸ andthat there is a negative association between anti-PC levels anddevelopment of human atherosclerosis¹⁹. Further, low levels of IgManti-PC were associated with systemic lupus erythematosus (SLE) in anested case-control SLE-study²⁰. No studies addressing anti-PC in RA andeffects of anti-TNF treatment have been performed. Anti-CD20 treatmenthas been shown to decrease total immunoglobulin, mostly IgM, and toinduce heterogeneous effects on antibody levels in rheumatic diseases²¹.The effects of B-cell depletion on anti-PC levels are still not known.

It is here reported how treatment with biologic agents, such asetanercept, infliximab, adalimumab and rituximab, during one yearinfluences levels of IgM anti-PC, oxidized low-density lipoprotein(oxLDL) and the apolipoprotein profile.

SUMMARY OF THE INVENTION

In summary, low levels of anti-PC predict a lack of response totreatment with biologics in RA. It has previously been demonstrated thatanti-PC have anti-inflammatory properties by inhibiting effects ofinflammatory phospholipids like PAF²⁰. This finding indicates thattreatment to inhibit such inflammatory reactions promoted byinflammatory phospholipids could potentiate the effect of biologics.

One important finding according to the present invention is that naturalantibodies against an epitope in the phospholipid moiety of membranesincluding oxLDL, IgM phosphorylcholine (anti-PC), increased during oneyear treatment of RA with TNF inhibitors, but decreased when patientswere treated with rituximab, a B-cell inhibitor. These observations mayhave several implications.

Anti-PC are natural antibodies, which were described in early studies asbeing of major importance in the early response to lethal infectionswith PC-exposing Meningococcae in mice²². PC may play different roles inimmune reactions, which may be both protective and deleterious²³.

It has been suggested that anti-PC are atheroprotective in humans, sinceanti-PC are negatively associated with atherosclerosis development¹⁹.Further, low anti-PC levels are independently associated with increasedrisk of CVD¹⁶⁻¹⁸. Also, it has previously been reported that individualsfrom Kitava, New Guinea, with a traditional life-style, have highanti-PC levels. Interestingly, these individuals do not seem to sufferfrom CVD and only to a very limited degree from rheumatic diseases²⁴. Inline with clinical studies, mice experiments indicate that both activeand passive immunization with anti-PC lead to decreased development ofatherosclerosis^(25, 26).

Without being bound by theory, there appear to be three potentialmechanisms by which anti-PC could protect against cardiovasculardisease. Firstly, anti-PC have anti-inflammatory and inhibiting effectson inflammatory phospholipids, such as platelet activating factor(PAF)²⁰. Another mechanism could be inhibition of macrophage uptake ofoxLDL by anti-PC¹⁸. Increased levels of anti-PC could in principleameliorate disease manifestations through inhibition of PAF, withimplications for chronic inflammatory diseases in general²⁷. A thirdmechanism could be prevention of plaque rupture by the inhibition of thecytotoxic effects of lysophosphatidylcholine, with implications foracute cardiovascular diseases in particular.

The effect of anti-PC IgM on the cytotoxic effects oflysophosphatidylcholine was investigated, and anti-PC IgM was found toreduce cell death in 2 different assays, thus lending support to theconcept that anti-PC IgM could prevent plaque rupture by the inhibitionof the cytotoxic effects of lysophosphatidylcholine.

Based on these findings, a novel hypothesis according to which lowlevels of anti-PC represent an immunodeficient state, thereby increasingrisk of chronic inflammatory, autoimmune and cancer diseases, isprovided according to the present invention. In this aspect, our findingthat anti-PC levels were significantly lower among non-responders tobiologic therapy than among responders opens the possibility thattreatment with anti-PC could potentiate other treatments and also have apositive effect per se in RA, as well as cardiovascular diseases andcancer. Furthermore, our finding that the combination of high anti-PClevels with high anti-MDA-LDL levels and/or high anti-OxLDL levels inthe ELSA study gave a strong protective effect against atherosclerosissuggests that a combination of these antibodies, as well as antibodiesagainst components, fragments or derivatives of MDA-LDL or OxLDL (suchas apoB100 or fragments thereof), would be more beneficial than singletherapies. The antibodies could either be endogenously produced as aresult of active immunization (vaccination), or exogenously administered(passive immunization). Likewise, our finding that a combination of lowIgM anti-PC with low anti-OxCL or low anti-OxPS increases the excessrisk of CVD would suggest that a combination of these antibodies couldalso improve therapy, if raised through active immunization or passiveimmunization.

The mechanism by which anti-TNF treatment was associated with increasedanti-PC levels in the present study of patients with RA is not clear.One possibility is that TNF has a direct inhibitory effect on B cellsproducing anti-PC, but it is also possible that anti-PC are increasedindirectly as a consequence of decreased inflammatory burden in general.Nevertheless, it is possible that a beneficial effect of anti-TNFtreatment on IgM anti-PC may contribute to cardioprotective effects ofthis therapy.

While anti-TNF treatment has been extensively studied in the context ofCVD, little is known about the risk of CVD associated with rituximabtreatment in rheumatic diseases. Two small studies indicate thatendothelial function may improve during such treatment^(14, 28).

In humans, treatment with rituximab induces an almost complete depletionof circulating B cells that usually lasts for 6 to 9 months, and inhumans and primates persistent partial B-cell depletion may be foundalso in bone marrow and lymphoid organs²⁹. Theoretically, depletion of Bcells in autoimmune diseases should be limited to conventional B2 cellswhile sparing regulatory B10 cells and potentially protective B1 cells,the producers of natural antibodies³⁰, but that has not been proven inhumans.

DETAILED SUMMARY OF THE INVENTION

One important finding herein is that rituximab treatment of RA patientswas associated with a decrease in IgM anti-PC levels. At present,previous studies where this association has been reported in RA have notbeen conducted. However, other publications indicate that some, but notall, antibodies decrease after B-cell depleting therapy. For example,levels of serum IgG, IgA and antibacterial antibody levels remainrelatively steady, whereas a single course of rituximab therapy leads tofall in titers of rheumatoid factor (RF), anti-citrullinatedprotein/peptide antibodies, anti-dsDNA and modest drops in serumIgM^(21, 31).

Accordingly, the present results could imply that treatment regimes withprolonged exposure of immune system to rituximab over time could causeincreased long-term risk of CVD, even though it may ameliorateshort-term negative effects of RA on CVD through its anti-inflammatoryproperties.

Both anti-TNF and rituximab treatment transiently worsened theoxLDL-status, which, however, returned to the baseline levels at the endof the study. To the best of our knowledge, possible changes ofcirculating oxLDL during therapy with biologics have not been examinedearlier.

In RA, dyslipidemia combined with enhanced activity of pro-inflammatorycytokines leads to a pro-oxidative state, which further promotesoxidation of low-density lipoprotein (LDL) to the highly atherogenicoxidized LDL (oxLDL). OxLDL has also pro-inflammatory effects, such asactivation of monocytes, endothelial cells, T cells and B cells³². Theimmunostimulatory and prothrombotic effects of oxLDL appear to bemediated through the platelet activating factor (PAF)-receptor, wherephosphorylcholine (PC) is the major ligand⁴. Interestingly, oxLDL andfoam cells are present in synovia in RA³³. Several studies in thegeneral population reported gradually increasing risk for CVD eventswith increasing plasma oxLDL^(34, 35).

A lot of attention has recently been focused on the apolipoproteins asCVD risk factors and important treatment target in the generalpopulation^(36, 37). In contrast with some studies, but in line withothers³⁸, we determined in both TNF and rituximab groups a beneficialincrease in apoA1, already evident after 3 months of follow-up, whichlasted during the one year of treatment without any distinct long-termchange in atherogenic index. The fact that these changes occurred inboth treatment groups suggests that the effect was not agent specificand an association with change of inflammatory activity was indeedfound. It is thus possible that after longer treatment periods animproved lipoprotein profile may contribute to the decreased risk of CVDreported in RA patients on TNF-inhibition treatment³⁹. Moreover, wenoted interesting lipid changes in patients having the lowest apoA1levels, the highest apoB levels, the highest atherogenic index or oxLDLlevels. Thus, patients most susceptible to future cardiovascular eventsshowed long-term improvement in apoA1, but at least short-term worseningin pro-atherogenic lipids without expected negative effect onatherogenic index.

In patients classified as responders according to the EULAR remissioncriteria, a transient moderate worsening in apoB and oxLDL without anyobvious long-term worsening of lipid profile was observed. Whether theseunfavorable and transient lipid changes could have some clinicalimportance is still not known. The inconsistency of the results inearlier reports regarding lipid changes during biologic therapy mayarise from the fact that studies had different treatment durations, wereconducted without consideration of the biologic efficacy and includedheterogeneous patient populations.

The strength of the present study is in its prospective design,structured collection of blood samples and information about RA statusat baseline, 3, 6 and 12 months of follow-up.

In summary, it is surprisingly found that levels of atheroprotective andanti-inflammatory anti-PC increased during anti-TNF treatment, butdecreased in patients treated with rituximab. The results of the studyextend beyond previous observations that apoA1 improves, but atherogenicindex remains stable, during long-term biologic treatment.

Based on the present invention, it is further surprisingly shown thatthe level of anti-PC is lower among non-responders to biologic agents intherapy of RA than among responders.

Thus, this invention relates to anti-PC that can play a role as a riskmarker and in the treatment of rheumatoid arthritis, other rheumatic,autoimmune, chronic inflammatory, cardiovascular and cancer diseases.

The invention further relates to the use of low anti-PC levels as a riskmarker, and high levels as a protective marker, so individuals at riskcould be identified and be eligible for treatment with anti-PC.

Even further, the invention also relates to the use of anti-PC as acomplement to other immunomodulatory RA treatments wherein biologics,such as TNF-inhibitors (and other cytokine-inhibitors) and/or rituximabor other biologics acting on immunocompetent cells, are used, e.g. as inthe treatment of RA.

The present invention also relates to antibodies against PC, PCconjugates and/or bioactive components and/or fragments thereof for usein combination and/or in combination therapy with biologic agents,especially for treating, preventing, and/or reducing the risk ofdeveloping chronic inflammatory, autoimmune and cancer diseases. Thus,antibodies against PC, PC conjugates and/or bioactive components and/orfragments thereof can be used in combination with other immunomodulatorytreatments, where biologics such as TNF-inhibitors (and othercytokine-inhibitors) and/or rituximab or other biologics acting onimmunocompetent B cells are used.

Biologic agents according to the present invention are of biologicalorigin and are used to diagnose or treat disease, and may includeproteins, peptides, cytokines, hormones, nucleic acids, lipids,phospholipids, carbohydrates, genetic resources, cells, organisms orparts thereof, populations, or any other biotic component of ecosystems.

Even further, biologic agents according to the present invention includestem cells, antibodies and fragments thereof, vaccines, interleukins andother cytokines, and may exhibit inhibitory effect on cytokine activity.Cytokine activity may be inhibited on the level of cytokine production,cytokine release, cytokine binding to cytokine receptors, and/orcytokine receptor activity, amongst others.

In accordance with the present invention, the term “cytokine” meansregulatory proteins or glycoproteins, secreted by white blood cells andvarious other cells in the mammalian organism in response to numerousstimuli, facilitating cell-to-cell communication. Cytokines regulate theintensity and duration of an immune response by stimulating orinhibiting the activation, proliferation and/or differentiation ofvarious cells, and by regulating the secretion of antibodies and othercytokines. In accordance with this invention, the group of cytokinesincludes, but is not limited to, interleukins (IL) and chemokines, aswell as cytokines known by common names, such as Interferons (IFN) andtumor necrosis factors (TNF).

Interleukins may be secreted by white blood cells, as well as variousother cells, and include the following interleukins, without beinglimited hereto: IL-1, IL-2, IL-3, IL-4, IL-5, IL-6, IL-7, IL-8, IL-9,IL-10, IL-11, IL-12, IL-13, IL-14, IL-15, IL-16, IL-17, IL-18, IL-19,IL-20, IL-21, IL-22, IL-23, IL-24 and IL-25.

Chemokines are mainly presented on white blood cells, however, notrestricted hereto. A non-exhaustive list of chemokines includes: IL-8,GCP-2 (granulocyte chemotactic protein 2), Gro-α (growth relatedoncogene α), Gro-β (growth related oncogene β), Gro-γ (growth relatedoncogene γ), NAP-2 (neutrophil activating protein), ENA-78(epithelial-cell-derived neutrophil-activating chemokine), IP-10(Interferon-inducible protein-10), Mig (monokine induced by interferoneγ), I-TAC (Interferon-inducible T-cell alpha chemoattractant), SDF-1(stromal cell-derived factor-1), PBSF (pre-B-cell growth stimulatingfactor), BCA-1 (B-lymphocyte chemoattractant 1), MIP-1 (macrophageinflammatory protein 1), RANTES (regulated upon activation, normalT-cell expressed and secreted), MIP-5 (macrophage inflammatory protein5), MCP-1 (monocyte chemoattractant protein 1), MCP-2 (monocytechemoattractant protein 2), MCP-3 (monocyte chemoattractant protein 3),MCP-4 (monocyte chemoattractant protein 4), Eotaxin, TARO (thymus- andacticvation-regulated chemokine), MIP-1α (macrophage inflammatoryprotein 1α), MIP-1β (macrophage inflammatory protein 1β), Exodus-1, ELC(Ebl1 ligand chemokine).

The term “white blood cells” means all blood cells which are notplatelets or red blood cells (i.e. erythrocytes), and are not limited tolymphocytes, monocytes, macrophages, dendritic cells, neutrophils,eosinophils and basophils. Natural killer cells, B- and T cells areincluded in the list of lymphocytes. Furthermore, the T cells may bedivided into subgroups, such as Th (helper) cells, CD8+ cytotoxic Tcells, regulatory (suppressor) T cells and gamma delta T cells. The termleukocytes may be used as a synonym for “white blood cells”.

Interferons in accordance with this invention are included in thefollowing non-exhaustive list: INF α, INF α-2a, INF α-2b, INF β, INF γ.

Tumor necrosis factors in accordance with this invention include, butare not limited to, TNF α and TNF β.

In accordance with the present invention, the term “cytokine production”means the synthesis of the cytokine inside white blood cells or variousother cells in the mammalian organism.

In accordance with the present invention, the term “cytokine release”means the process of translocation of the cytokine from the interior ofthe cell to the exterior; the term “secretion” may also be used in thisregard.

In accordance with the invention, the term “cytokine binding to cytokinereceptor” means the specific binding of cytokines to receptors on themembrane of the target cell. The cytokine may bind receptors on themembrane of the same cell (autocrine action), to a receptor on a targetcell in close proximity (paracrine action) and/or to distant targetcells presenting the cytokine receptor (endocrine action).

In accordance with the invention, the term “cytokine receptor activity”means the triggering of a signal-transduction pathway, upon binding ofthe cytokine to the cytokine receptor as defined above, that ultimatelyalters gene-expression in the target cell.

In a particular embodiment of the present invention, biologic agents maybe selected from the group comprising TNF blockers, such as, but notlimited to, etanercept, infliximab, adalimumab, certolizumab pegol,golimumab, interleukin 1 (IL-1) blockers, such as, but not limited to,anakinra, monoclonal antibodies against B cells, such as, but notlimited to, rituximab, T-cell costimulation blockers, such as, but notlimited to, abatacept, Interleukin 6 (IL-6) blockers, such as, but notlimited to, tocilizumab, or other antibodies, such as, but not limitedto, antibodies against oxidized phospholipids and/or oxidizedlipoproteins and/or fragments or derivatives thereof, such as, but notlimited to, antibodies against apoB100 and/or fragments or derivativesthereof, anti-MDA-LDL, anti-OxLDL, anti-oxCL or anti-oxPS.

Since biologic agents, such as Rituximab, may inhibit natural antibodieslike anti-PC, and also may have a favourable effect on chronicinflammatory diseases like RA and SLE, the role of B cells in thesediseases is coming more and more in focus. Therefore, other B-cellinhibiting agents are also of interest according to the presentinvention if they cause decreases in anti-PC levels.

In accordance with the present invention, the term “mammal” means allknown mammals, and in particular mice, rats, rabbits, dogs, cats,cattle, horses and humans.

In accordance with the present invention, the medicament may beadministered by any suitable means known by the skilled person and beformulated with excipients and adjuvants normally employed for suchmedicaments and their corresponding formulations. In particular, themedicament may be intended for administration by injection, optionallytogether with any suitable excipients and adjuvants employed for suchformulations. Alternatively, the medicament may be given in the form ofa pill, tablet or capsule.

The medicament may be administered in a way so as to be compatible withthe dosage formulation and in such amount as will be therapeuticallyeffective and/or immunogenic.

In accordance with the present invention, any agent that is suitable forincreasing the anti-PC response, in particular PC conjugates, PC orbioactive components and/or parts thereof, optionally in combinationwith any suitable adjuvants, is to be considered as part of thisinvention. Such PC-exposing compounds also include platelet activatingfactor (PAF), PAF-like lipids or lysophosphatidylcholine, which havepro-inflammatory effects where PC is an important mediator.

In accordance with the present invention, monoclonal, polyclonal orchimeric antibodies of isotype IgA, IgD, IgE, IgG, IgM, raised againstPC, PC conjugate or bioactive components and/or parts/fragments thereof(e.g. where PC is a component, such as is the case in PAF or PAF-likelipids), refer to any monoclonal or polyclonal antibody produced byimmunization of a suitable mammal, including, but not limited to, mouse,rabbit, goat, sheep, or horse.

In accordance with the present invention, the term “bodily fluid” meansany natural bodily fluid or secretion of fluid including, but notlimited to, plasma, serum, blood, urine, or saliva.

In accordance with the present invention, the term “combination therapy”means the individual or simultaneous administration of two or moremedications to treat a single disease and/or diseases that may developdue to unwanted medical side-effects or lack of satisfactory positivepharmaceutical response from the administration of one of themedications, e.g. unwanted medical side-effects due to theadministration of biologic agents to treat chronic inflammatorydiseases, autoimmune disease and cancer diseases.

In accordance with the present invention, “chronic inflammatorydiseases, autoimmune and cancer diseases” means any of—including, butnot limited to—the following diseases: cardiovascular disease (CVD),such as atherosclerosis, atheromatous plaque rupture, myocardialinfarction, acute coronary syndrome, stroke, transient ischemic attack(TIA), claudication, angina pectoris; diabetes mellitus type 1 and 2,Alzheimer's disease, dementia in general, rheumatic diseases, acuteand/or chronic inflammatory conditions, rheumatoid arthritis, psoriasis,psoriatic arthritis, ankylosing spondylitis, Reiter's Syndrome, systemiclupus erythematosus, dermatomyositis, Sjogren's syndrome, multiplesclerosis, myasthenia gravis, encephalitis, inflammatory bowel disease,arthritis, idiopathic inflammatory myopathies (IIM), dermatomyositis(DM), polymyositis (PM), inclusion body myositis, spondylopathies,vasculitis (including Wegeners granulomatosus, Takayasu arteritis,temporal arteritis), polymyalgia rheumatica, bowel disease includingCrohn's disease and colitis of different kinds, nephritis, asthma, orcancer diseases, such as, but not limited to, non-Hodgkin's lymphoma,colorectal cancer, head and neck cancer and breast cancer and/or othercancer diseases where immunomodulation is used as treatment.

Immunotherapy is normally defined within medicine as “treatment ofdisease by inducing, enhancing, or suppressing an immune response”.Passive immunity can be achieved through the transfer of ready-madeantibodies into the affected individual or mammal. Immunotherapiesdesigned to elicit or amplify an immune response are normally termed“activation immunotherapies”, and include, for example, immunization.Immunotherapies designed to reduce, suppress or more appropriatelydirect an existing immune response, as in cases of autoimmunity orallergy, are normally termed “suppression immunotherapies”. The activeagents of immunotherapy are collectively called “immunomodulators”, andinclude a wide variety of natural, synthetic and recombinant substances,many of which are biological agents as defined above. Examples ofimmunomodulators include medicinal mushrooms and herbs, various plantand microorganism extracts, vaccines, adjuvants, hormones, variousdrugs, interleukins, interferons and other cytokines.

Further, a detailed description of antibodies against PC conjugate, PCor bioactive components and/or fragments can be found in WO10/003602. Asdescribed in the '602 application, a PC-conjugate is a PC moiety linkedto a carrier, optionally via a spacer. The structural element PC may, ormay not, comprise a derivative of PC. The carrier can be, for example, aprotein, a carbohydrate, a lipid, a polymer, latex beads, or colloidmetal. The PC-conjugate may for example be a protein-PC conjugate, suchas a human serum albumin (HSA)-PC conjugate, a keyhole limpet hemocyanin(KLH)-PC conjugate or a bovine serum albumin (BSA)-PC conjugate.Examples of PC-conjugates and generation of anti-PC antibodies are,e.g., described in WO 2005/100405 and U.S. Pat. No. 5,455,032, thecontents of which are hereby included by reference. Thus, based on thisit is clear that monoclonal antibodies reactive against PC conjugate,anti-PC or bioactive components and/or fragments can be produced usingany standard method known in the art. See for example Briles et al.,1982. J Exp Med 156, 1177-1185 or Spira et al., 1988. J. Immunology 140,2675-2680. Other antibodies against a phosphorylcholine and/or itsconjugate can be prepared using methods well known to those skilled inthe art. For example, a sub-fraction with anti-PC activity of a humanimmunoglobulin preparation can be prepared as described below byaffinity purification using a PC conjugate.

Further, intravenous immunoglobulin preparations (e.g., IGIV; Baxter andothers) are highly purified preparations of IgG commercially availableand are used in the treatment of patients who have no, or very lowlevels, of antibody production. Immunoglobulin preparations includethose available from the following manufacturers: Baxter (US), e.g.,Gammagard®, Isiven (Antimo Naples, Italy), Omrix (Tel-Hashomer, Israel),Miles (Biological Products Division, West Heaven, Conn.), Sclavo (Lucca,Italy), Sandoz (Novautis, Basel, Swizeriand), e.g., Sandoglobulin®,Biotest Diagnostic Corporation (Deville, N.J.). Examples ofimmunoglobulin preparations are GammagardS/D®, GammarIV®, Gaimnar-PIV®,Gammimune N®, Iveegam®, Panglobulin®, Polygam S/D®, Sandoglobulin®,Venoglobulin®. Immunoglobulin preparations typically contain some IgM aswell as IgG. Trace amounts of IgM are present in Gammagard®. Pentaglobin(Biotest) is an enriched IgM preparation, which has been used fortreatment of SARS. The subfraction with anti-PC activity may compriseboth IgG and IgM, or may be selected to comprise mainly IgG (for exampleby starting with an IgG-rich preparation, such as Gammagard® and/or byselecting for IgG); or mainly IgM (for example by starting with anIgM-rich preparation such as Pentaglobin and/or by selecting for IgM).

Further, an antibody preparation with specificity to a PC conjugatebinds to unconjugated PC and may also bind to PC present inPC-containing compounds, in which PC is exposed, for example inlysophosphatidylcholine (see for example, Kim et al., 2002 J Exp Med.196, 655-65). Thus, an antibody preparation with specificity to a PCconjugate may also bind to lysophosphatidylcholine or otherphospholipids or phospholipid-containing compounds as plateletactivating factor (PAF) or PAF-like lipids which have PC as a majorcomponent.

An embodiment of the present invention is thus to use PC conjugates orPC or bioactive components and/or parts thereof for the preparation of apharmaceutical composition to be used in a treatment, prophylaxis and/orprevention prior to treatment of a mammal with biologic agents curingautoimmune diseases, chronic inflammatory diseases, and cancerousdiseases. The conjugate can be PC linked to a pharmaceuticallyacceptable protein, carbohydrate, or polymer. The pharmaceuticalcomposition is preferably given by injection, but can in practice beadministered by any suitable means that allows the PC conjugate toprovoke an immune response in the subject to which it is administered.The proposed method of active immunization will modulate the titre ofanti-PC antibodies, which in turn will have a positive effect on thedevelopment of autoimmune diseases, chronic inflammatory diseases, andcancerous diseases. Thus, active immunization may be used to increasethe titre of anti-PC antibodies to a level that, when assessed by themethods of diagnosis according to the present application, would not besaid to be “low” or indicative of an increased risk of development, orprogression, of autoimmune diseases, chronic inflammatory diseases, andcancerous diseases. Thus, a method of active immunization according tothe present invention may be used to increase anti-PC levels, such asIgM anti-PC levels, in an individual to a level that is greater thanabout 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60, 65, 70, 75, or 80 U/mlwhen tested by the methods described above. Accordingly, the method ofactive immunization according to the present invention may be used toincrease anti-PC levels to a level that is above the mean average, orabove a particular percentile value determined with reference to thewider population, such as above the 5th, 10th, 20th or 25th percentile,such as to a level, wherein the odds ratio is below one, the p-value is<0.05 and the upper limit of the odd ratio confidence interval is lessthan one, indicating a statistically significant level of low risk.

Another embodiment of the invention concerns the use of an antibodypreparation, for example a monoclonal antibody, recognizing PCconjugates or PC or bioactive components and/or parts thereof for thepreparation of a pharmaceutical composition to be used in a treatment,prophylaxis and/or prevention prior to treatment of a mammal withbiologic agents for curing autoimmune diseases, chronic inflammatorydiseases, and cancerous diseases. The monoclonal antibody can beproduced using methods known in the art. Other antibody preparations maybe used, such as anti-PC enriched preparations obtained from intravenousimmunoglobulin preparations, recombinantly produced anti-PC antibodiesand/or other artificially created anti-PC antibody derivatives, asdiscussed above. Thus, passive immunization may be used to increase thetitre of anti-PC antibodies in an individual to a level that, whenassessed by the methods of diagnosis according to the presentapplication, would not be said to be “low” or indicative of an increasedrisk of development, or progression, of autoimmune diseases, chronicinflammatory diseases, and cancerous diseases. Thus, a method of passiveimmunization according to the present invention may be used to increaseanti-PC levels, such as IgM anti-PC levels, in an individual to a levelthat is greater than about 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, 60,65, 70, 75 or 85 U/ml when tested by the methods described above.Accordingly, the method of active immunization according to the presentinvention may be used to increase anti-PC levels to a level that isabove the mean average, or above a particular percentile valuedetermined with reference to the wider population, such as above the5th, 10th, 20th or 25th percentile, such as to a level wherein the oddsratio is below one, the p-value is <0.05 and the upper limit of the oddratio confidence interval is less than one, indicating a statisticallysignificant level of low risk.

One embodiment of the invention relates to antibodies against PC, PCconjugate or bioactive components and/or fragments thereof for use incombination therapy with one or more biologic agents and/or stem cellsin a mammal. The antibodies can be used for curing, treating,preventing, and/or reducing the risk of developing autoimmune diseases,chronic inflammatory diseases, or cancerous diseases in a mammal, andcan be monoclonal, polyclonal or chimeric antibodies of isotype IgA,IgD, IgE, IgG, IgM, optionally in combination with any suitableexcipients or adjuvants. In preferred embodiments, the biologic agentsare selected from the group comprising tumor necrosis factor alpha(TNFa) blockers, such as, but not limited to, etanercept, infliximab,adalimumab, certolizumab pegol, golimumab, Interleukin 1 (IL-1)blockers, such as, but not limited to, anakinra, monoclonal antibodiesagainst B cells, such as, but not limited to, rituximab, T cellcostimulation blocker, such as, but not limited to, abatacept,Interleukin 6 (IL-6) blockers, such as, but not limited to, tocilizumab,or other antibodies, such as, but not limited to, antibodies againstoxidized phospholipids and/or oxidized lipoproteins and/or fragments orderivatives thereof, such as, but not limited to, antibodies againstapoB100 and/or fragments or derivatives thereof, anti-MDA-LDL,anti-OxLDL, anti-oxCL or anti-oxPS. In particularly preferredembodiments, the biologic agents comprise one or more of the antibodiesanti-MDA-LDL, anti-OxLDL, anti-oxCL and anti-oxPS.

Another embodiment according to the invention relates to antibodiesagainst PC, PC conjugate or bioactive components and/or fragmentsthereof for immunization, treating, preventing, and/or reducing the riskof developing autoimmune diseases, chronic inflammatory diseases, andcancerous diseases in a mammal, said mammal being in therapy withbiologic agents.

Yet another embodiment according to the invention relates tocompositions comprising antibodies against PC, PC conjugates orbioactive components and/or fragments thereof in combination with one ormore biologic agents and/or stem cells, particularly for use as amedicament, especially for curing, treating, preventing, and/or reducingthe risk of developing autoimmune diseases, chronic inflammatorydiseases, or cancerous diseases in a mammal.

Yet another embodiment according to the invention relates to antibodiesagainst PC, PC conjugates or bioactive components and/or fragmentsthereof, or compositions comprising them, for use in preventing therupture of atheromatous plaques.

Yet another embodiment according to the invention relates to antibodiesagainst PC, PC conjugates or bioactive components and/or fragmentsthereof, or compositions comprising them, for use in preventing ortreating cancer.

Yet another embodiment according to the invention relates to PCconjugates, PC or bioactive components and/or parts/fragments thereoffor use in activation immunotherapy prior to or in combination(combination therapy) with the treatment of a mammal with biologicagents and/or stem cells for curing, treating, preventing, and/orreducing the risk of developing autoimmune diseases, chronicinflammatory diseases, and cancer diseases. In preferred embodiments,the biologic agents are selected from the group comprising tumornecrosis factor alpha (TNFa) blockers, such as, but not limited to,etanercept, infliximab, adalimumab, certolizumab pegol, golimumab,Interleukin 1 (IL-1) blockers, such as, but not limited to, anakinra,monoclonal antibodies against B cells, such as, but not limited to,rituximab, T cell costimulation blocker, such as, but not limited to,abatacept, Interleukin 6 (IL-6) blockers, such as, but not limited to,tocilizumab, or other antibodies, such as, but not limited to,antibodies against oxidized phospholipids and/or oxidized lipoproteinsand/or fragments or derivatives thereof, such as, but not limited to,antibodies against apoB100 and/or fragments or derivatives thereof,anti-MDA-LDL, anti-OxLDL, anti-oxCL or anti-oxPS. In particularlypreferred embodiments, the biologic agents comprise one or more of theantibodies anti-MDA-LDL, anti-OxLDL, anti-oxCL and anti-oxPS.

Yet another embodiment according to the invention relates to PCconjugates, PC or bioactive components and/or parts/fragments thereoffor use in preventing the rupture of atheromatous plaques.

Yet another embodiment according to the invention relates to PCconjugates, PC or bioactive components and/or parts/fragments thereoffor use in preventing or treating cancer.

Yet another embodiment according to the invention relates to the use ofantibodies against PC, PC conjugates or bioactive components and/orfragments thereof, or compositions comprising them, in preventing therupture of atheromatous plaques.

Yet another embodiment according to the invention relates to the use ofantibodies against PC, PC conjugates or bioactive components and/orfragments thereof, or compositions comprising them, in preventing ortreating cancer.

Yet another embodiment according to the invention relates to the use ofPC conjugates, PC or bioactive components and/or parts/fragments thereofin preventing the rupture of atheromatous plaques.

Yet another embodiment according to the invention relates to the use ofPC conjugates, PC or bioactive components and/or parts/fragments thereofin preventing or treating cancer.

A further embodiment according to the invention relates to a compositioncomprising phosphorylcholine (PC), PC conjugate and/or bioactivecomponents and/or fragments thereof in combination with biologic agents.In preferred embodiments, the biologic agents are selected from thegroup comprising tumor necrosis factor alpha (TNFa) blockers, such as,but not limited to, etanercept, infliximab, adalimumab, certolizumabpegol, golimumab, Interleukin 1 (IL-1) blockers, such as, but notlimited to, anakinra, monoclonal antibodies against B cells, such as,but not limited to, rituximab, T cell costimulation blocker, such as,but not limited to, abatacept, Interleukin 6 (IL-6) blockers, such as,but not limited to, tocilizumab, or other antibodies, such as, but notlimited to, antibodies against oxidized phospholipids and/or oxidizedlipoproteins and/or fragments or derivatives thereof, such as, but notlimited to, antibodies against apoB100 and/or fragments or derivativesthereof, anti-MDA-LDL, anti-OxLDL, anti-oxCL or anti-oxPS. Inparticularly preferred embodiments, the biologic agents comprise one ormore of the antibodies anti-MDA-LDL, anti-OxLDL, anti-oxCL andanti-oxPS.

Experimental

The materials and methods and examples disclosed below are provided onlyfor the purpose of illustrating the present invention and should not beconsidered as any limitation of the scope as outlined in the appendedclaims.

Patients and Methods Patients

In all, 215 outpatients with RA (ACR criteria 1987)⁴⁰ were identifiedfrom a prospective cohort of RA patients registered in the localdatabase including all patients treated with biologics at theRheumatology Department, Karolinska University Hospital Huddinge. Theystarted their treatment with anti-TNF (etanercept, infliximab andadalimumab) or rituximab between January 2000 and October 2007 and wereincluded consecutively in this study in case they had been treated forat least one year, moreover, in case of TNF-treatment, if they had beenbiologic-naive earlier. At this time, Rituximab was used mainly inpatients that had failed on anti-TNF-therapy, and thus, 68% of thesepatients had got anti-TNF treatment earlier. Rituximab was the firstbiologic in case of history of recurrent infections, lymphoma, lungfibrosis or family history of multiple sclerosis. Concomitantdisease-modifying antirheumatic drugs (DMARD) were chosen by thetreating physicians in accordance with the current recommended treatmentstrategy in Sweden.

Assessments of disease activity had been done at treatment initiationand after 3, 6 and 12 months. These included the composite diseaseactivity score DAS28⁴¹, CRP, ESR and the modified version of StanfordHealth Assessment Questionnaire, HAQ⁴².

In addition, from medical records information was obtained on RA diseasecharacteristics, traditional CVD risk factors (current and previoussmoking, hypertension and diabetes mellitus), history of CVD (myocardialinfarction, congestive heart failure, angina pectoris and stroke),medications and also blood pressure and body mass index (BMI). Currenthypertension was defined as a blood pressure above 140/90 mmHg or beingtreated with anti-hypertensive drugs. The study was approved by theEthics committee at Karolinska Institute, Stockholm, Sweden, referencenumber 2008/159-31, and was performed in accordance with the Helsinkideclaration.

Serum Analyses

Sera were obtained at baseline, and at 3, 6 and 12 months of follow-up,and stored at −70° C. until all samples were analyzed. Anti-PC IgM andoxLDL were determined by ELISA (Athera Biotechnologies AB, Stockholm,Sweden and Mercodia AB, Uppsala, Sweden, respectively) according to theprotocols provided by the manufacturers and essentially as describedearlier^(17, 43). Apolipoproteins A1 (ApoA1) and B (ApoB) weredetermined by an immunoturbidimetry (Modular Analytics P, RocheDiagnostics).

Statistical Analysis

Clinical characteristics were compared between groups usingKruskal-Wallis test for multiple samples or Mann-Whitney U test for twosamples for continuous variables, chi-square test or Fisher's exact testfor dichotomous variables. We employed McNemar's test for dichotomousoutcomes in analysis of differences in one sample at differenttime-points. The association between baseline level of antibodies andprogression of clinical characteristics was determined using Spearmanrank correlation. To analyze changes in IgM anti-PC, oxLDL,apolipoprotein levels and influence of independent covariates on primaryoutcomes we used linear mixed model with correction for random effectsin the complete longitudinal dataset, the assumptions for analysis werevalid. Log transformations were undertaken if needed in order to obtainnormality of variable distributions. Level of significance was chosen tobe α<0.05. Calculations were performed using STATISTCA, release 8 (StatSoft Scandinavia AB, Tulsa, Okla., USA).

DAS stands for “Disease Activity Score” and is a measure of the activityof rheumatoid arthritis. In Europe, the DAS method is the recognizedstandard in research and clinical practice and a well-known terminologyordinary to the skilled person.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1. Changes of IgM anti-PC levels from baseline over 3, 6 and 12months of follow-up in the anti-TNF total and Rituximab groups. Adjusted(sex, age, smoking habits) LS means are shown, where the vertical barsdenote 0.95 confidence intervals. Post-hoc test (pooled MSE, between andwithin effects considered) was used for comparisons at different timepoints.

FIG. 2. Panel A and B represent anti-PC changes in responders vs.non-responders as to remission (DAS28<2.6) in anti-TNF total andrituximab groups under the follow-up. Original data log transformed,adjusted (sex and age) LS means where vertical bars denote 0.95confidence intervals. Post-hoc test (pooled MSE, between and withineffects considered) was used for comparisons at different time points.DAS28=disease activity score calculated on 28 joints.

FIG. 3. Effect of antibodies against phosphorylcholine (anti-PC) IgMantibodies on lysophosphatidylcholine (LPC) induced necrosis, expressedas fluorescent measure of leakage of lactate dehydrogenase from cellswith a damaged membrane in PBMC. (300,000 cells/well, 96 well plates)were incubated with LPC for 2 h and LDH activity in supernatant wasmeasured. Anti-PC or control antibodies which did not bind PC, werepreincubated with LPC 90 minutes before starting the treatment. Theresults were expressed as units per liter of LDH.

FIG. 4. Effect of human IgM antibodies on lysophosphatidylcholine (LPC)induced cytotoxicity, measured as decrease in mitochondrialdehydrogenaze activity in PBMC. (3,000,000 cells/well) were incubatedwith LPC for 18 h and the mitochondrial dependent reduction of MTT toformazin was measured. Anti-PC, total IgM and IgM which did not bind PC(flow through) were preincubated with LPC 90 minutes before starting thetreatment. The results were expressed percentage of viable cellscompared with non stimulated cells (control).

EXAMPLE 1: EFFECTS OF BIOLOGIC AGENTS ON LEVELS OF ANTIBODIES AGAINSTPHOSPHORYLCHOLINE Results

Demographic and clinical characteristics of the patients studied aresummarized in Table 1.

The characteristics were similar for the etanercept, infliximab andadalimumab patients, apart from a lower proportion of currenthypertension in patients offered etanercept and a higher proportion ofconcomitant use of methotrexate (MTX) among patients startinginfliximab, the latter in conformity to treatment recommendation.

Patients started on Rituximab were older, had longer disease duration,higher frequency of RF-positivity and occurrence of erosive jointdisease than the anti-TNF treated patients. These patients were lesscommonly treated with MTX but instead more often with other DMARDs(azathioprine, sulfasalazine, leflunomide, cyclosporine, gold) and withglucocorticoids (GC). Furthermore, they were more often previoussmokers, had higher frequency of CVD comorbidity and treatment withstatins.

In all treatment groups, history of hypertension was relatively frequentand mean BMI close to borderline for overweight (BMI>25 kg/m²), with nostatistical differences between treatment groups.

Disease Activity and Function

All patients had high disease activity at baseline measured by DAS28,CRP and ESR and low functional capacity measured by HAQ, with nointergroup difference for the anti-TNF agents. However, patients startedon Rituximab had significantly higher DAS28 and HAQ-score than theanti-TNF treated groups, table 1.

Already at the 3-month follow-up, about ⅔ of the patients in alltreatment groups experienced significant improvement according to DAS28;thus, mean±SD DAS28 in the total TNF-group vs. the Rituximab group was3.9±1.2 and 4.2±1.3, respectively. This positive effect was presentduring the whole follow-up period, reaching a mean±SD DAS28 3.7±1.5 vs.4.5±1.6 at the end of the study. At both the 3 and 12 month follow-ups,patients on anti-TNF treatment had significantly lower DAS28 than theRituximab treated patients, p=0.026 and p=0.002 respectively, with nointra group difference. However, the change in DAS28 throughout thestudy period did not differ significantly between anti-TNF andanti-B-cell treated subjects, p=0.108.

Physical ability improved during follow-up as well; thus, HAQ-score at12 months had decreased, mean±SD, 0.3±0.5 in anti-TNF treated patientsand with 0.2±0.4 in Rituximab-treated subjects, without significantintra group differences for TNF-α treatments or difference betweenanti-TNF vs. rituximab group, p=0.618 and p=0.118 respectively.

Concomitant Treatment

The DMARD therapy was fairly constant during the study period. The GCtreatment could be stopped in low percentages of the patients andsimilarly in all treatment groups. At the 12-month visit, the Rituximabgroup was still significantly more often treated with GC, 73.6% vs.27.2% for the anti-TNF treated groups, p<0.0001. However, the daily GCdosage had been decreased more in the Rituximab group at the 12-month offollow-up, at which time the intergroup difference had disappeared. Inall groups the use of NSAID diminished during the study period.Treatments against hypertension and hyperlipidemia were unchanged duringthe study period.

Levels of Antibodies Against Phosphorylcholine (Anti-PC) of IgM Subclass

At baseline, anti-PC levels were higher in the etanercept and lower inthe adalimumab-treated subjects compared with the infliximab andrituximab groups, p=0.001. There was no statistically significantdifference in baseline anti-PC between the TNF group total vs. therituximab group, p=0.444.

In the whole anti-TNF group, anti-PC had increased significantly alreadyafter 3 months of therapy, and a further increase was evident at both 6and 12 months, table 2. In the separate anti-TNF groups, there was atrend towards increasing antibody levels after 3 months of treatment inall three groups, reaching statistical significance at 12 months inpatients on etanercept and infliximab therapy, but not on adalimumab (ahigh percentage of missing data at 6 and 12 months of follow-up, 33 an23% respectively, was noted in this group). In contrast to anti-TNFtreatment, in patients receiving rituximab there was a statisticallysignificant decrease in anti-PC levels at 12 months, table 2.

At all time-points of follow up, the anti-PC levels were significantlyhigher in total anti-TNF group vs. Rituximab-treated group as presentedin FIG. 1 (adjusted for sex, age and smoking habits). The curveillustrating anti-PC increase in the total anti-TNF group contrasts withthose of B cells therapy where a continuous declining trend was noted.The overall treatment effect on antibody levels was strikingly evidentwith high statistical significance (p<0.0001). Thus, beneficial effectson IgM anti-PC on TNF-blockade, but disadvantageous effects on rituximabwere observed during the 12 months' study period.

A large between and within individual variation in antibody levels wasconsistently noticed in all treatment groups throughout the studyperiod, with positive covariance of mild-grade 0.55-0.73 for subjectshaving TNF-a treatment and of low-grade 0.11-0.26 for the Rituximabgroup.

Subgroup analysis revealed that anti-PC levels at baseline weresignificantly lower in male compared with female, median (IQR) 37.8(26.88-65.78) vs. 55.63 (33.13-96.70) U/ml, p=0.007. Analysis restrictedto subgroups of TNF-treated patients revealed that there was a tendencytowards a more prominent increase in antibody levels in females and inmiddle-aged patients without a history of smoking (data not shown). Thisgender discrepancy may be one explanation why the increasing levels ofanti-PC levels in subjects offered adalimumab (with a higher frequencyof males compared with the two other anti-TNF groups) did not reachstatistical significance. We did not find significant influence of anybaseline variables on anti-PC decrease in the rituximab treatedsubjects.

Association Between IgM Anti-PC Levels and Disease Activity

There were no significant correlations between anti-PC concentration atthe beginning of treatment and initial levels of the inflammatorymarkers CRP, ESR, DAS28 or with lipid profile measured as apoA1, apoBand apoB/apoA1 ratio.

In the anti-TNF total group, baseline levels of anti-PC differed insubjects responding vs. those not responding to treatment. Thus,patients achieving remission at 12 months, DAS28<2.6, on anti-TNFtreatment had significantly higher baseline anti-PC levels than thosenot in remission, p=0.007, and this difference in anti-PC levels waspresent at all follow-up time-points (FIG. 2A). Also in patients onrituximab, baseline anti-PC levels were higher in those who laterachieved remission, p=0.041 (Figure. 2B).

For the anti-TNF total group, there were negative correlations betweenabsolute change (Δ) in anti-PC with changes in both clinical activityand physical ability from baseline to 12 months of follow-up as follows:r=−0.17, p=0.033 for ΔCRP, r=−0.21, p=0.010 for ΔESR; r=−0.18, p=0.029for ΔDAS28; r=−0.17, p=0.05 for ΔHAQ. Relative changes in anti-PCcorrelated quite well with absolute changes of clinical characteristics.Thus, the change in anti-PC level was associated with overall decreaseof inflammation in patients on anti-TNF treatment. In the rituximabgroup there was no evident relation between anti-PC and clinicalvariables.

Levels of oxLDL and Apolipoproteins

OxLDL levels at baseline differed significantly between the anti-TNFgroups but not between the anti-TNF total vs. the rituximab group. TheoxLDL levels were shown to be lower with increasing age, theage-depended oxLDL difference showed statistical significance, p=0.002,(age categorized <45, 45-65 and >65 years old). No difference in oxLDLlevel was detected in regard to other patients' characteristics.

Baseline concentrations of apoA1, apoB and apoB/apoA1 ratio did notdiffer statistically between the treatment groups (Table 3). Mean apoA1was normal, >1.29 g/l, but a pro-atherogenic profile was shown for apoBand apoB/apoA1 ratio; thus, mean apoB was >0.88 g/l and mean apoB/apo1ratio was >0.69 in all study subgroups.

OxLDL had increased significantly at 3 months of therapy on adalimumab,anti-TNF total and on rituximab treatments, but this increase wanedthereafter to almost initial levels (Table 3).

ApoA1 levels increased somewhat on the various therapies—at 3 months inthe total anti-TNF group, at 6 months in the total anti-TNF and in therutuximab group, and towards 12 months apoA1 stabilized but maintainedstill higher levels than at baseline. Thus, at the end of follow-upapoA1 had increased, on average, by 8.5% on etanercept, by 2.3% in theanti-TNF total and by 6.7% on rituximab, with no significant intergroupdifference.

The atherogenic ratio, apoB/apoA1, and apoB did not change significantlyover time and remained relatively stable throughout the whole studyperiod, except for the adalimumab treatment group where a small rise inapoB was detected after 3 months of follow-up, this increase disappearedand apoB levels reverted to initial levels after 6 months of therapy.

Previous population-based studies suggest that apolipoproteins areuseful predictors of risks for CVD. However, cut-off levels forapolipoproteins in RA population are not established. With regard topossible CVD risks, we performed analysis after tertiary subdividing ofinitial blood lipids. Data was dichotomized according to the 33%percentile for apoA1 and the 66% percentile for oxLDL, apoB andapoB/apoA1. Because of small sample sizes, analyses were limited to theanti-TNF total vs. the rituximab-treated groups (Table 4).

The biologic treatments resulted in an initial increase in percentage ofsubjects with high oxLDL and apoB, which was followed by a beneficialdecrease to approximately initial levels at 12 months in patients onanti-TNF, but remained still high in patients on rituximab. Onrituximab, the percentage of subjects with elevated apoB, despite morefrequent use of statins, was statistically higher than in the anti-TNFtotal group at 6 months of follow-up, p=0.042.

The frequency of subjects with low apoA1 in the anti-TNF group decreasedat 3-6 months of follow-up and then increased towards 12 months, but wasthen still lower than at the treatment initiation. In the rituximabgroup, the frequency of patients with low apoA1 was consistentlydecreasing throughout the whole study period. There was no between-groupdifference.

Seemingly, as shown in table 4, the TNF-blockade in comparison withrituximab induced opposite effects on apoB/apoA1 ratios at 3-6 months offollow-up, but no statistically significant between-group difference wasobserved. Anyway, a slightly lower percentage of subjects with elevatedatherogenic index was shown at 12 months in both groups.

Thus, both anti-TNF and rituximab treatments caused short-termimprovement in the lowest apoA1 tertile but transient increases of apoBand oxLDL levels in the highest tertile without unequivocal influenceson atherogenic index during one year of the study period. Besides, theresults suggest that TNF-a blockade and B cells therapy may havedifferent effects on lipid profile.

Association Between Lipid Levels and Disease Activity

Associations between lipid changes and changes in inflammatory markersduring the period of follow-up were similar in the patients onTNF-blockade and rituximab. In the whole study population, absolutechange (A) in oxLDL levels were inversely correlated with ΔCRP at 3months, r=−0.18, p=0.009; at 6 months, r=−0.26, p=0.001, and at 12months, r=−0.24, p=0.001. In the same way, a low-moderate negativeassociation was observed between ΔapoA1 and ΔCRP at 3 months, r=−0.17,p=0.108, at 6 months, r=−0.23, p=0.002, and at 12 months, r=−0.27,p=0.0001. We did not detect any obvious associations between apoB,apoB/apoA1 ratio and changes in disease activity.

In order to investigate if the lipid changes varied according toclinical response, we performed sub-analysis (sex and age adjusted)according to EULAR remission criteria DAS28<2.6 at 12 months in theanti-TNF total and the rituximab groups.

At baseline, 3 and 12 months there were no significant differences instudied lipid levels between responders and non-responders, neither inthe anti-TNF total group nor in the rituximab group, with exception ofapoB, where responders had lower initial apoB level, on average 14.3%,p=0.037.

At 6 months, however, lipid levels were significantly, but stillmoderately, lower among responders in regard to levels of oxLDL, 7%,p=0.003 on anti-TNF and 7%, p=0.017 on Rituximab treatment; and inregard to levels of apoA1, on average 16.1%, p=0.004; apoB, 12.1%,p=0.005 on anti-TNF therapy. There was no difference in the atherogenicindex between responders and non-responders.

Thus, a temporary difference in oxLDL, apoA1 and apoB in patients onTNF-blockade and in oxLDL in patients on rituximab was registeredbetween subjects achieving clinical remission and those not achieving itafter one year of biologic therapy.

TABLE 1 Baseline demographic and clinical characteristics of the RApatients, by treatment group Etanercept Infliximab Adalimumab TNF-atotal Rituximab n = 60 n = 60 n = 42 p¹-value n = 162 n = 53 p²-valueAge, yrs 54.6 ± 12.5 56.6 ± 12.2 57.9 ± 12.7 0.38 56.2 ± 12.4 63.3 ±10.7 0.0001 Age, RA-onset, yrs 43.7 ± 13.5 46.1 ± 12.8 47.4 ± 14.6 0.4345.6 ± 13.5 49.4 ± 11.6 0.045 Female, n (%) 47 (78.3) 43 (71.7) 27(64.3) 0.29 117 (72.2) 45 (84.9) 0.06 Duration of RA, yrs 7.5 (5-14) 9(4-15) 5 (3-11) 0.34 7 (4-14) 11 (7-17) 0.003 RF-positivity, n (%) 51(85.0) 51 (85.0) 30 (71.4) 0.15 132 (81.5) 52 (98.1) 0.003 Erosivedisease, n (%) 54 (90.0) 52 (86.7) 31 (73.8) 0.07 137 (84.6) 51 (96.2)0.026 Current smoker, n (%) 14 (23.3) 16 (26.7) 9 (21.4) 0.69 39 (24.1)9 (17.0) 0.32 Previous smoker, n (%) 4 (6.0) 9 (15.0) 9 (21.4) 0.12 22(13.6) 18 (34.0) 0.035 CVD comorbidity, n (%) 14 (23.3) 20 (33.3) 12(28.6) 0.48 46 (28.4) 25 (47.2) 0.012 History of hypertension, 13 (21.7)17 (28.3) 12 (28.6) 0.64 42 (25.9) 19 (35.9) 0.16 n (%) Currenthypertension, n 27 (48.2) 40 (69.0) 23 (69.7) 0.040 90 (61.2) 32 (60.4)0.91 (%) Current diabetes 2 (3.3) 6 (10.0) 1 (2.4) 0.06 9 (5.6) 7 (13.2)0.07 mellitus, n (%) Statin use, n (%) 3 (5.0) 2 (3.3) 1 (2.4) 0.80 6(3.7) 6 (11.3) 0.040 BMI, kg/m² 24.2 ± 4.4  25.3 ± 3.9  25.9 ± 5.2  0.3025.2 ± 4.6  25.9 ± 4.5  0.33 CRP, mg/l 25 (10-42) 23 (10-38) 15 (9-58)0.64 22 (10-41) 28 (14-57) 0.11 ESR, mm/hr 39 (27-49) 34 (27-55) 35.5(19-64) 0.912 41.2 ± 24.0 36 (28-65) 0.25 DAS28 5.6 ± 0.9 5.7 ± 1.0 5.6± 1.3 0.857 5.7 ± 1.0 6.1 (±1.1) 0.010 HAQ-score 1.2 ± 0.7 1.4 ± 0.6 1.4± 0.6 0.219 1.3 ± 0.6 1.5 ± 0.5 0.033 DMARD use: MTX, n (%) 38 (63.3) 58(96.7) 30 (71.4) <0.0001 126 (77.8) 23 (43.4) <0.0001 Other DMARDs 9(15.0) 10 (16.7) 6 (14.3) 0.94 25 (15.4) 22 (41.5) 0.0001 n (%) GC use,n (%) 19 (31.7) 18 (30.0) 17 (40.5) 0.51 54 (33.3) 42 (79.3) <0.0001 GC,mg/day 5.5 ± 1.6 5.0 (5-7.5) 7.5 (5-8.8) 0.15 5 (5-7.5) 7.5 (5-15)0.0001 NSAID, n (%) 44 (73.3) 42 (70.0) 26 (61.9) 0.462 112 (69.1) 31(58.5) 0.154 Except where indicated otherwise, values are denoted asmean ±SD or median (IQR) depending on values distribution. p¹ indicatesp-value for differences between the three TNF-a offered treatmentgroups, p² for differences between TNF-a total and B cells therapygroups. Bold p-values are statistically significant. CVD =cardiovascular disease, BMI = body mass index, DAS28 = disease activityscore for 28 joints, HAQ = health assessment questionnaire, DMARD =disease modifying anti-rheumatic drug, GC = glucocorticoid, NSAID =non-steroidal anti-inflammatory drug, yrs = years.

TABLE 2 Antibody levels of IgM subclass against phosphorylcholine(anti-PC) at baseline and changes at the follow-up time-points, bytreatment group anti-PC, Etanercept Infliximab Adalimumab Anti-TNFtotalRituximab U/ml n = 60 n = 60 n = 42 n = 162 n = 53 baseline 67.61(46.4-115.8) 41.59 (33.6-88.5) 36.59 (24.3-64.6) 51.61 (32.9-94.5) 42.88(31.6-81.5) Δ 3-0 6.87 (−4.54; 26.83) 2.56 (−6.23; 11.98) 0.07 (−1.91;8.56) 2.25 (−4.03; 13.24) −5.2 (−10.69; −1.64) p-value 0.15 >0.5 >0.50.012 0.35 Δ 6-0 4.99 (−3.86; 34.73) 6.46 (−2; 12.3) −0.85 (−4.08; 7.1)3.92 (−3.63; 19.6) −6.11 (−11.35; −0.35) p-value 0.28 >0.5 >0.50.001 >0.5 Δ 12-0 8.67 (−5.82; 42.6) 8.47 (−2.05; 19.14) 4.73 (−1.99;15.23) 8.27 (−2.38; 27.92) −8.02 (−15.28; −1.14) p-value 0.0020.046 >0.5 <0.0001 0.023 Results are indicated as median (IQR). Δ =changes; 3-0, 6-0 and 12-0 concern differences between respectiveperiods of follow-up, 3, 6 and 12 months and 0 = baseline. p-values aregiven for changes in anti-PC between the respective time-points and aremarked in bold if statistically significant. The number of patients wasin the etanercept group 60 at all time-points; in the infliximab group60 at baseline, 58 at 3 months, 48 at 6 months and 58 at 12 months; inthe adalimumab group 42 at baseline, 42 at 3 months, 28 at 6 months and32 at 12 months; and for the rituximab group 53 at baseline, 50 at 3months, 52 at 6 months and 48 at 12 months.

TABLE 3 Lipid levels at baseline and changes at the follow-uptime-points, by treatment group Lipids Etanercept Infliximab AdalimumabAnti-TNFtotal Rituximab oxLDL, U/l Baseline 74 (56.8-95.1) 67.26 ± 19.7 57.86 ± 20.32 64.7 (51.9-83.8) 61.18 ± 17.47 Δ 3-0 0.14 ± 27.3  2.48 ±12.77  5.85 ± 13.44  2.49 ± 19.66  3.67 ± 12.18 p = 0.75 p = 0.10  p =0.004  p = 0.011  p = 0.023 Δ 6-0  1.39 ± 28.47 1.3 (−6.8; 11.2)  0.33 ±19.01  2.05 ± 22.88  2.75 ± 11.95 p = 0.54 p = 0.26 p = 0.88 p = 0.20 p= 0.10 Δ 12-0 1.79 ± 29.4 −0.24 ± 13.98 2.9 (−5.3; 12.4)  0.55 ± 22.10 2.37 ± 14.26 p = 0.39 p = 0.80 p = 0.35 p = 0.31 p = 0.31 ApoA1, g/lBaseline 1.29 ± 0.31 1.34 ± 0.30 1.28 ± 0.29 1.31 ± 0.28 1.34 ± 0.28 Δ3-0 0.03 (−0.16; 0.2) 0.05 ± 0.31 0.10 ± 0.31 0.04 ± 0.32 0.03 ± 0.25 p= 0.70 p = 0.11  p = 0.017  p = 0.013 p = 0.30 Δ 6-0 0.03 (−0.07; 0.16)0.06 (−0.07; 0.2) 0.02 ± 0.39 0.07 (−0.08; 0.19) 0.09 ± 0.32  p = 0.037p = 0.23 p = 0.31  p = 0.012  p = 0.022 Δ 12-0 0.11 ± 0.22 0.03 (−0.18;0.16) 0.01 ± 0.47 0.03 ± 0.36 0.09 ± 0.32  p = 0.0001 p = 0.87 p = 0.53 p = 0.007 p = 0.06 ApoB, g/l Baseline 0.88 ± 0.22 0.90 ± 0.28 0.92 ±0.28 0.90 ± 0.26 0.95 ± 0.25 Δ 3-0 −0.04 ± 0.23  0.05 ± 0.22 0.07 ± 0.200.02 ± 0.22   0 ± 0.18 p = 0.46 p = 0.09  p = 0.042 p = 0.11 p = 0.97 Δ6-0 0 (−0.09; 0.11) −0.01 ± 0.21  −0.06 ± 0.23  −0.02 ± 0.21  0.03 ±0.18 p = 0.77 p = 0.80 p = 0.20 p = 0.51 p = 0.19 Δ 12-0 0.04 ± 0.17−0.01 ± 0.25  −0.05 (−0.2; 0.15) 0.03 (−0.11; 0.13) 0.03 ± 0.22 p = 0.12p = 0.78 p = 0.48 p = 0.47 p = 0.67 B/A1 ratio Baseline 0.70 ± 0.21 0.70± 0.24 0.74 ± 0.25 0.71 ± 0.23 0.68 (0.61-0.85) Δ 3-0 −0.02 ± 0.15  0.01± 0.17 0.02 ± 0.18 0.003 ± 0.16  −0.01 ± 0.14  p = 0.50 p = 0.60 p =0.64 p = 0.95 p = 0.78 Δ 6-0 −0.02 ± 0.13  −0.03 (−0.11; 0.08) −0.05 ±0.20  −0.03 (−0.11; 0.07) −0.02 ± 0.15  p = 0.37 p = 0.45 p = 0.23 p =0.11 p = 0.56 Δ 12-0 −0.03 ± 0.11   0.02 ± 0.19) −0.06 ± 0.20  −0.02 ±0.17  −0.02 ± 0.17  p = 0.12 p = 0.57 p = 0.22 p = 0.31 p = 0.25 Resultsare indicated as mean ± SD or median (IQR) depending on valuesdistribution. Δ = changes; 3-0, 6-0 and 12-0 concern differences betweenrespective periods of follow-up, 3, 6 and 12 months and 0 = baseline,the number of patients as indicated in table 2. p-values are given forchanges in the lipids between the respective time-points and are markedin bold if statistically significant. There were no significant groupdifferences between total anti-TNF vs. rituximab treatment. OxLDL =oxidized low-density lipoprotein, apoA1 = apolipoprotein A1, apoB =apolipoprotein B, B/A1 = apoB/apoA1.

TABLE 4 Changes in patient percentages above the 66% percentile ofoxLDL, apoB and apoB/apoA1 and below the 33% percentile of apoA1,respectively, during the study, by treatment groups Anti-TNF totalRituximab p⁴-value OxLDL 66 percentile U/l >76.5    >65.2   baseline, %[CI] 33.3 [26.1; 40.6] 33.9 [21.2; 46.7] 3 months, % [CI] 37.5 [30.0;45.0] 38.0 [24.6; 51.5] 0.95 p¹-value 0.0003 0.029 6 months, % [CI] 38.2[30.1; 46.4] 44.2 [30.7; 57.7] 0.45 p²-value <0.0001  0.012 12 months, %[CI] 30.2 [22.8; 37.6] 39.6 [25.7; 53.4] 0.23 p³-value 0.0001 0.029ApoA1 33 percentile, g/l <1.19   <1.18  baseline, % [CI] 33.3 [31.8;34.6] 34.0 [21.2; 46.7] 3 months, % [CI] 25.6 [18.8; 32.4] 22.0 [10.5;33.5] 0.604 p¹-value 0.0001 0.003 6 months, % [CI] 23.7 [16.5; 30.9] 17.3 [7.0; 27.6] 0.34 p²-value 0.0001 0.001 12 months, % [CI] 30.0[22.7; 37.3]  20.8 [9.3; 32.3] 0.22 p³-value 0.0001 0.004 ApoB 66percentile, g/l >1.02 g/l >0.98  baseline, % [CI] 33.3 [26.0; 40.6] 32.1[19.5; 44.7] 3 months, % [CI] 36.3 [28.8; 43.7] 42.0 [28.3; 55.7] 0.46p¹-value 0.0002 0.046 6 months, % [CI] 30.4 [22.6; 38.1] 46.2 [32.6;59.7] 0.042 p²-value 0.001  0.012 12 months, % [CI] 32.7 [25.2; 40.2]41.7 [27.2; 55.6] 0.26 p³-value 0.0002 0.032 ApoB/A1 ratio 66percentile >0.78   >0.79  baseline, % [CI] 33.3 [26.1; 40.6] 32.1 [19.5;44.6] 3 months, % [CI] 36.3 [28.8; 43.7] 26.0 [13.8; 38.2] 0.18 p¹-value0.0002 0.010 6 months, % [CI] 34.8 [26.8; 42.8] 26.9 [14.9; 39.0] 0.30p²-value 0.006  0.007 12 months, % [CI] 32.0 [24.5; 39.5] 31.3 [18.1;44.4] 0.92 p³-value 0.0002 0.034 Frequency of patients is indicated as %[0.95 confidence interval]. p¹, p² and p³ estimate changes between 0-3,0-6 and 0-12 months respectively. p⁴ estimates difference betweentreatment groups. p-values <0.05 are assumed to be statisticallysignificant, marked as bold. OxLDL = oxidized low-density lipoprotein,apoA1 = apolipoprotein A1, apoB = apolipoprotein B.

EXAMPLE 2: INHIBITION OF LYSOPHOSPHATIDYLCHOLINE INDUCED CELL DEATH BYANTI-PC IGM

Peripheral blood mononuclear cells (PBMC) in 96 well plates (with300,000 cells/well) were incubated with lysophosphatidylcholine (LPC)for 2 h, and cell death was assessed by measuring lactate dehydrogenase(LDH) activity in the supernatant. Antibodies against phosphorylcholine(anti-PC IgM) or control antibodies which did not bind PC, werepreincubated with LPC 90 minutes before starting the treatment. Theresults were expressed as units per liter of LDH. As can be seen fromFIG. 3, anti-PC IgM reduced cell death more than total IgM andflowthrough IgM.

PBMC (3,000,000 cells/well) were incubated with LPC for 18 h, and celldeath was assessed by measuring the decrease in mitochondrial dependentreduction of MTT to formazin. Anti-PC, total IgM and IgM which did notbind PC (flow through) were preincubated with LPC 90 minutes beforestarting the treatment. The results were expressed as percentage ofviable cells compared with non-stimulated cells (control). As can beseen from FIG. 4, anti-PC IgM reduced cell death more than total IgM orflowthrough IgM.

EXAMPLE 3: PROTECTIVE EFFECT OF COMBINATION OF HIGH ANTI-PC WITH HIGHANTI-MDA-LDL OR HIGH ANTI-OXLDL ELSA-Study Materials and MethodsSubjects

Serum samples were obtained from 226 subjects with establishedhypertension (diastolic pressure >95 mm Hg) prior to their entry intothe Swedish component of the European Lacidipine Study onAtherosclerosis (ELSA)^(44, 45). Samples were collected following a4-week washout period without medication to minimize the effects oftreatment on the measured parameters. Blood pressure, cholesterol andtriglyceride levels were determined as described previously^(44, 45) Onehundred and fifteen of the subjects were subsequently assigned totreatment with the β-blocker atenolol, and 111 of the subjects wereassigned to treatment with the calcium antagonist lacidipine.

Carotid ultrasound determinations were performed and analysed asdetailed elsewhere^(19,44,45). A total of 226 patients had validultrasound measurements at baseline and after 4 years of follow up.Briefly, the right and left carotid arteries were examined with Biosound2000 IIA duplex scanner using a 8.0 MHz annular array transducer. Theintima-media (I-M) thickness was determined in the far wall as thedistance between the leading edge of the lumen-intima echo and theleading edge of the media-adventitia echo. The outcome measurement as asurrogate indicator for atherosclerosis was the change in mean maximumIntimal-Medial thickness (IMT) of the four far walls in the distalcommon carotids and carotid bifurcations bilaterally (CBMmax) at the4-year follow-up. The associations between antibody levels to PC atenrolment into the study with an increase or decrease in IMT at the4-year follow-up were evaluated.

IgM antibodies to PC-BSA were determined by enzyme-linked immunosorbentassay (ELISA). Pooled serum from the same donors was used as an internalstandard and tested on every plate. The plateau of antibody binding wasreached with the antigen concentration of 10 μg/ml. F96 microtiterpolysorp plate was therefore coated with PC-BSA (10 μg/ml) 50 μl/well inPBS. Coated plates were incubated overnight at 40 C. After five washingswith PBS, the plates were blocked with 2% BSA-PBS for 2 h at roomtemperature and washed as described above. Serum samples were diluted(1:30) in 0.2% BSA-PBS and added at 50 μl/well.

LDL was isolated from plasma of healthy donors by sequential preparativeultra-centrifugation and oxidized by use of copper ions (OxLDL) orderivatized with MDA (MDA-LDL) as described¹¹. OxLDL and MDA-LDL weredetermined by ELISA essentially as described¹¹. OxLDL or MDA-LDL wasdiluted to 2 μg/ml in coating buffer (carbonate-bicarbonate buffer 50 mMpH 9.7), and 100 μl/well was used to coat ELISA plates (Costar 2581).The plates were kept at 4° C. overnight, washed 4 times with PBS, andthen blocked with 20% adult bovine serum in PBS (20% ABS-PBS) for 2hours in room temperature. They were then incubated with 100 μl serum,diluted 1:30 in 20% ABS-PBS at 4° C. overnight.

Plates were incubated overnight at 4° C. and washed as described above.Alkaline phosphatase conjugated goat anti-human IgG (diluted 1:9000 inthe sample buffer) and Alkaline phosphatase conjugated goat anti-humanIgM (diluted 1:7000 in the sample buffer) were added at 100 ul/well andincubated at 4° C. overnight. After five washings, color was developedby adding the Alkaline phosphatase substrate (PNPP) at 100 ul/well andincubating the plates for 60 min at room temperature in the dark. Theplates were read in an ELISA Multiskan Plus spectrophotometer (MolecularDevices Emax, San Francisco) at 405 nm. All samples were measured in asingle assay and the coefficient of variation was below 10-15%.

Results

Details of the study on Basic characteristics and anti-PC, anti-OxLDLand anti-MDA-LDL separately has been presented elsewhere¹⁹.

When high anti-MDA-LDL and high anti-PC (both IGM) or high anti-OxLDLand high anti-PC (both IgM) where combined, surprisingly, theassociations with decreased development of atherosclerosis (protectioneffect) were strongly and significantly raised (table 6).

Conclusion

Anti-PC IgM as a protection factor becomes stronger when combined withanti-MDA-LDL or anti-OxLDL, suggesting that a combination of theseantibodies, raised through active immunization (vaccination) or passiveimmunization (where antibodies are administered), has advantages ascompared to single therapies.

TABLE 5 Basic characteristics of the study group at enrolment. Resultsare presented as means (SD) or percentage (%) and mg/dL for lipids.Total Atenolol Lacidipine (N = 226) (N = 115) (N = 111) Age (years) 57.7(7.8) 57.6 (7.6) 57.7 (7.9) Sex (% males) 50 46 53 BMI 26.7 (3.7) 26.3(3.3) 27.1 (3.9) Total Cholesterol 232.4 (37.8) 233.5 (38.1) 231.4(37.4) HDL 55.6 (27.6) 56.5 (25.8) 54.7 (27.6) LDL 149.4 (37.8) 149.7(37.1) 149.2 (38.6) Triglycerides 131.6 (58.2) 128.6 (57.0) 134.7 (59.5)

TABLE 6 prediction of changes in IMT with baseline levels of IgMautoantibodies to phosphorylcholine (PC) or MDA-LDL. (95% CI) VariableOdds Ratio Lower Upper p aMDA-LDL (highest .67 .36 1.2 .18 25^(th)percentile Anti-PC (highest 10^(th) .36 .15 0.87 .024 percentile)aMDA-LDL (IgM) and .14 .038 0.512 .003 anti-PC (combined)

TABLE 7 prediction of changes in IMT with baseline levels of IgMautoantibodies to phosphorylcholine (PC) or Ox-LDL. (95% CI) VariableOdds Ratio Lower Upper p aOx-LDL (highest 25^(th) .84 0.46 1.56 0.4percentile Anti-PC (highest 10^(th) .36 .15 0.87 .024 percentile)aOx-LDL (IgM) and .12 .033 0.42 .003 anti-PC (as above, combined)

EXAMPLE 4: INCREASED RISK OF CVD FROM COMBINATION OF LOW IGM ANTI-PCWITH LOW ANTI-OXCL OR LOW ANTI-OXPS Study of 60-Year Olds

Objective.

We here determine the role of IgM antibodies against phosphorylcholine(anti-PC) in combination with antibodies against oxidized cardiolipin(anti-OxCL) or antibodies against oxidized phosphatidylserine(anti-OxPS) in prediction of cardiovascular disease (CVD).

Methods.

From a screening of 4232 subjects, 60-years old (2039 men and 2193women), 211 incident cases of CVD (myocardial infarction, ischemicstroke, or hospitalized angina pectoris) and 633 age- and sex-matchedcontrols were identified through a 5-7 year follow-up^(18,46,47). Serumlevels of antibodies was determined by ELISA. Cardiolipin andphosphatidylserine was oxidized in aqueous solutions containing 1.5mmol/L tert-butylhydroperoxide and CuSO₄ in 20 μmol/L.

Results.

In women, there were no significant associations between anti-PC andCVD. Among men, individuals with anti-PC levels in lowest quartile 4(lowest) as the reference value yielded a trendwise excess risk for CVD(p=0.069) which was not significant. However when combined with lowanti-OxCL or low anti-OxPS (both below 25th percentile), associationsbecame significant with an increase from p=0.069 to p=0.042 (whencombined with anti-OxCL) and 0.024 (when combined with anti-OxPS).

Conclusions.

A combination of low IgM anti-PC with low anti-OxCL or low anti-OxPSincreases the excess risk of CVD. A combination of these antibodiescould improve therapy, if raised through active immunization or passiveimmunization.

All references as listed below and discussed in the above descriptionare hereby incorporated by reference in their entirety.

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1. A method for increasing the efficacy of a biological agent forcuring, treating, preventing, and/or reducing the risk of developingrheumatoid arthritis, said method comprising: identifying an individualthat is a non-responder to rituximab; and administering rituximab incombination with PC as part of activation immunotherapy to thenon-responder, wherein said mammal is selected from the group comprisingrabbits, dogs, cats, horses and humans.
 2. The method of claim 1,wherein administering the rituximab comprises co-administering rituximabsimultaneously with the PC.